By Taylor Sisk
Last December, Tim Murphy, a Republican member of the U.S. House of Representatives from Pennsylvania, introduced a bill that came out of a yearlong investigation into the nation’s mental health system. The results of that study left Murphy, a clinical psychologist, “profoundly shocked to learn just how archaic and ineffective federal mental-health policy is in our country.”
The Murphy bill, co-sponsored by North Carolina Rep. Renee Ellmers (R-2nd District), is built upon measures designed to address the needs of those living with the most severe and persistent mental illnesses. After the May multiple shootings in Santa Barbara, California, Murphy spoke of both his anguish for families destroyed and anger that “Washington hasn’t had the courage” to fix our mental health care system.
The federal government, he wrote in a Philadelphia Inquirer op-ed, “has never approached serious mental illness as a health-care issue.”
Murphy wrote that what he proposed would be “the most significant overhaul of the nation’s mental-health system since President John F. Kennedy established community mental-health centers 51 years ago.”
“How many more people must lose their lives before we take action on addressing cases of serious mental illness?” he asked.
But some mental health experts have cautioned against expecting that even a significant overhaul of the system can prevent such tragedies as occurred in Santa Barbara, Newtown and elsewhere.
Jeffrey Swanson, a professor in the Duke University School of Medicine’s Department of Psychiatry and Behavioral Sciences, has written that while “it remains impossible to reliably predict which specific individuals would otherwise engage in the most serious acts of violence,” potential acts of violence could be prevented in the future “if mental health services were more consistently available and accessible to all those who need them, and especially to those with known risk factors for harming others or themselves.”
Most all experts agree that something must be done to more effectively address mental illness. But opinions on how to do so vary.
Rep. Ron Barber, a Democratic representative from Arizona who was hurt in the mass shooting that also injured Rep. Gabby Giffords, has introduced an alternative mental health bill, one that endorses more community-based, “person-centered” services, including early intervention, outreach, rehabilitation and peer support.
Given the makeup of the current Congress, Barber’s bill stands much less chance of passage than Murphy’s. But its proponents hope that, at the least, some of its provisions will make it into final legislation.
Ellmers wrote in a statement that she supports the Murphy bill because, “Across the country, our mental health system is in need of reform, and North Carolina is no exception.”
She cited a rise in the state’s suicide rate over the past decade, from 18 percent to more than 22 percent. “In the military alone,” she wrote, “more soldiers have died by their own hand than in battle this year.”
Several provisions in the Murphy bill are widely regarded as positive steps – funding for law-enforcement training, reauthorization of a program that serves students with mental health or substance-abuse issues on college campuses, funding for suicide-prevention programs and expansion of telepsychiatry grant money, among them.
But several others have generated much debate.
For many of those who have big issues with the Murphy bill, the trouble begins with its title, the “Helping Families in Mental Health Crisis Act.” Barber’s bill is titled the “Strengthening Mental Health in Our Communities Act.”
According to Vicki Smith, executive director of Disability Rights North Carolina, the difference in those titles “speaks volumes.”
The Murphy bill proposes a change to the Health Information Portability and Accountability Act, or HIPAA, that would give physicians and mental health professionals the authority to disclose “protected health information” to family members or other caregivers about a loved one who is believed to be in a mental health crisis.
The intent is to better protect that loved one, who, it’s presumed, requires help making good choices.
The Bazelon Center for Mental Health Law counters in a critique of the Murphy bill that “it is people with psychiatric disabilities who are often most in need of privacy protections due to widespread prejudices and stereotypes.”
And, Smith said, people with mental illness often do know what’s best for themselves, and that may run contrary to what the family thinks is best.
She’s similarly concerned about language in the Murphy bill regarding court-ordered assisted outpatient treatment, or AOT, the bill’s most hotly debated provision.
AOT allows a court official to order outpatient services as an alternative to institutionalization if it’s deemed that the person’s mental illness is leading to repeated arrest or hospitalization or to violence. The bill proposes providing grants to counties, cities, mental health systems, mental health courts and others to set up AOT pilot programs.
A study of New York State’s AOT program conducted by a team of Duke researchers found that people who received court-ordered AOT “appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.”
North Carolina is among 45 states with AOT laws.
Mike Weaver, who serves on the National Alliance for Mental Illness board of directors and works in the Office of Consumer Affairs for Kannapolis-based Cardinal Innovations Healthcare Solutions, said that many people with mental health issues look at AOT as “punitive.”
“AOT is an excuse to not have effective engagement,” he said.
Weaver, who has bipolar disorder, advocates for a philosophy of treatment that is a “welcoming, engaging, positive therapeutic alliance.”
Laurie Coker, director of the North Carolina Consumer Advocacy, Networking, and Support Organization, said that “forced treatment is inconsistent with a recovery focus.”
Recovery is the objective, she said, and helping a person recover is about helping them to live more assertively, to make their own choices, to focus on their responsibilities.
Forcing treatment, Coker said, “removes a person’s voice and his will from the equation.”
Weaver contends that the reason New York’s law has been successful is that the state has put significant resources into providing a range of services that people need.
A hit to advocacy agencies
A third provision of the Murphy bill that’s of considerable concern to many mental health advocates is a proposed 85 percent cut in funding for Protection and Advocacy Programs for Individuals with Mental Illness, or PAIMI. Disability Rights NC is North Carolina’s federally mandated protection and advocacy agency.
The provision would also prohibit PAIMI agencies from lobbying, from using federal funding to engage in “systemic lawsuits” or investigate and seek legal remedies in any cases other than individual cases of abuse or neglect and from providing counsel to an individual with a serious mental illness “who lacks insight into their condition on refusing medical treatment or acting against the wishes of such individual’s caregiver.”
Smith said limiting legal action to abuse and neglect would prevent Disability Rights NC from advocating for people who are facing discrimination, most particularly, in housing and employment.
“The PAIMI program has always been a little bit controversial, in that, like any of our programs, our client is the individual with the disability,” she said. “We’re pretty clear about that, and that’s the way it should be.”
But Smith said Disability Rights NC also has “very effective relationships with families and family organizations.”
She said she believes that the work protection and advocacy agencies do is distorted when the focus is placed on the fact that they sometimes will tell clients they have the right to refuse treatment.
“Mostly what we’re trying to do is to work with our clients to get the treatment they want and need,” Smith said.
The case that’s most often cited in challenging treatment-refusal advocacy is that of William Bruce, a 24-year-old Maine man diagnosed with schizophrenia who was released from a psychiatric facility despite his doctors’ objections and two months later murdered his mother.
Smith contends that the discussion of such tragedies must include an examination of whether the system failed the individual who committed the act of violence and, if so, how. In the case of Bruce, she said, public opinion squarely placed the blame on the PAIMI program that supported his desire to be released.
The protection and advocacy program is funded by the Substance Abuse and Mental Health Services Administration. Murphy has indicated he believes that many of the federal agency’s programs aren’t based on firm evidence. He’s called for cuts to many of those programs and a curtailment of SAMHSA’s authority.
Mental health a bipartisan issue
The Barber bill proposes no changes to HIPPA, provides no money for assisted outpatient treatment pilot programs, reauthorizes and maintains protection and advocacy programs and calls for reauthorization of SAMHSA’s primary initiatives but with new oversight requirements.
Barber told Behavioral Healthcare Magazine that he doesn’t want to pit his bill against Murphy’s. “I hope we can find a bipartisan path forward,” he said. “Mental illness doesn’t have a partisan flavor to it, when it strikes a family or an individual.”
While emphasizing that he recognizes that sometimes people need inpatient care, his focus, he said, is on community-based services, because “that is what works best.”
No action has been taken on the Murphy bill since it was heard in subcommittee in April. Though primarily backed by fellow Republicans, Murphy has received support from 24 Democrats.
The Barber bill was referred to the Subcommittee on Early Childhood, Elementary, and Secondary Education on June 13.
Meanwhile, Vicki Smith dreams of the promise of John F. Kennedy’s Community Mental Health Act, whereby people living with mental illness exit institutions and return to communities in which well-funded treatment facilities complement working-wage jobs and affordable housing.
“There’s no entitlement in the Murphy bill, or now, that says a person with severe and persistent mental illness has a right to treatment,” Smith lamented. “If they had a right to treatment, I think some of what’s in that bill wouldn’t be necessary.”